Inspire Mentor Application

INSPIRE is a mentor program for newly affect individuals. An oversight committee, approved by the Board of Directors, is in the process of designing a standard operating procedure for INSPIRE. Individuals will submit an application to serve as either a mentor or mentee. The oversight committee will screen each individual application for participation in INSPIRE according to established criteria. The committee will then match approved mentors with approved mentees after both mentors and mentees complete any and all necessary training.

• Date of Application / MM / DD YYYY
• Name First Last
• Address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country
• Age
• Sex
  Male Female
• Home Phone - (###) - ### ####
• Cell Phone - (###) - ### ####
• Email
• Available Date

• Education

• Highest Degree
• Area(s) of Study

• Occupation

• Job/Position

• What motivates you to serve as a mentor with Inspire? What strengths/skills do you bring to this role? If selected as a mentor, we may select a portion of your response as part of Inspire's marketing to the public.

• Reference 1 First Last
• - (###) - ### ####
• Reference 2 First Last
• Phone - (###) - ### ####

• Submitting this form indicates that I have voluntarily applied to serve as a Mentor with the LIVE Consortium, Inc. Inspire Program. I affirm that the information I have provided in this application is true and accurate to the best of my knowledge. If selected, I agree to serve for a minimum of 6 months on a voluntary basis and comply with the procedures of the Inspire Program.